Citation, DOI & article data
Relatively common, lower esophageal rings are found in ~6-14% of oesophagrams 9.
More than half of patients will have an associated esophageal condition such as 2:
Most commonly, it presents as intermittent dysphagia, especially to solid food. A history of food impaction is also very common. Dysphagia is more common in patients with an associated motility disorder.
The pathogenesis of the Schatzki ring is unclear with conflicting hypotheses that include redundant pleats of mucosa, congenital abnormalities and modified peptic strictures. Interestingly, there is a reduced incidence of Barrett esophagus in patients with a Schatzki ring.
Depending on its luminal diameter, an esophageal B-ring may be symptomatic or asymptomatic 4:
- <13 mm: almost always symptomatic
- 13-20 mm: sometimes symptomatic
- >20 mm: rarely symptomatic
When it is symptomatic, it is termed a "Schatzki ring".
Schatzki rings are located at the gastro-esophageal junction, illustrated by the fact that there is squamous epithelium above and columnar epithelial below the ring. They should not be confused with
- A-rings, which are found a few centimeters proximal to the B-ring
- esophageal webs, which are lined on both sides by esophageal mucosa 6-8
Single-contrast barium swallows (especially in the RAO prone position) are more sensitive than endoscopy in detecting Schatzki rings 3. On barium swallow the following features may be seen 1:
- full-column barium swallow will reveal a circumferential narrowing at the gastro-esophageal junction, often a few centimeters above the diaphragmatic hiatus
- thin smooth ring, 1-3 mm
Sensitivity can be improved by:
- performing a Valsalva maneuver
- using barium tablet or barium-coated marshmallow
Double-contrast barium studies are less sensitive
Treatment and prognosis
Treatment of Schatzki ring is done with four-quadrant biopsy, bougies or pneumatic balloon dilatation 9.
History and etymology
Schatzki rings are named after Richard Schatzki (1901-92), an American physician, who was born in Germany 1. His co-author on his article introducing his eponymous ring was John E Gary (1916-1970), a radiology colleague at Mount Auburn Hospital in Cambridge, Massachusetts, hence its occasional moniker, a Schatzki-Gary ring 10.
On fluoroscopy consider
- 1. Kanne JP, Rohrmann CA, Lichtenstein JE. Eponyms in radiology of the digestive tract: historical perspectives and imaging appearances. Part I. Pharynx, esophagus, stomach, and intestine. Radiographics. 26 (1): 129-42. doi:10.1148/rg.261055084 - Pubmed citation
- 2. Müller M, Gockel I, Hedwig P et-al. Is the Schatzki ring a unique esophageal entity?. World J. Gastroenterol. 2011;17 (23): 2838-43. Free text at pubmed - Pubmed citation
- 3. Pezzullo JC, Lewicki AM. Schatzki ring, statistically reexamined. Radiology. 2003;228 (3): 609-13. doi:10.1148/radiol.2283021162 - Pubmed citation
- 4. Gore RM, Levine MS. Textbook of Gastrointestinal Radiology. Saunders. (2008) ISBN:1416023321. Read it at Google Books - Find it at Amazon
- 5. Liu, Julia J., and Peter J. Kahrilas. "Pharyngeal and esophageal diverticula, rings, and webs." GI Motility online (2006).
- 6. Smith MS. Diagnosis and management of esophageal rings and webs. Gastroenterol Hepatol (N Y). 2011;6 (11): 701-4. Free text at pubmed - Pubmed citation
- 7. Nurko S, Teitelbaum JE, Husain K et-al. Association of Schatzki ring with eosinophilic esophagitis in children. J. Pediatr. Gastroenterol. Nutr. 2004;38 (4): 436-41. Pubmed citation
- 8. Patel B, Han E, Swan K. Richard Schatzki: a familiar ring. AJR Am J Roentgenol. 2013;201 (5): W678-82. doi:10.2214/AJR.13.10748 - Pubmed citation
- 9. Lucas D. Watts, Krunal Patel. Schatzki Ring. (2020) Pubmed
- 10. Schatzki R. John E. Gary, M.D. 1916-1970. (1970) The American journal of roentgenology, radium therapy, and nuclear medicine. 110 (3): 644-5. doi:10.2214/ajr.110.3.644 - Pubmed